Pre Exercise | Treatment Questionnaire

Please answer some basic information about yourself prior to booking an appointment with us, as at CCKM, we like to ensure all activities is personalised for each person. This information ensures we understand a little of your needs and goals prior to you meeting with us.

For all visitors at the club, please read and agree to the Terms of Participation and Exclusion Clause in the link below.

Open & read the Terms of Participation and Exclusion Clause

By digitally submitting this form, you agree to the Terms of Participation (full document in link above), for all forms of training or services provided by PERSONAL TRANSITION also known as CLOSE COMBAT and agree to the Exclusion Clause.

Fill in the participant details and by selecting the AGREE & SUBMIT button below, you have

  1. Agreed that you- the participant is at least 18 years of age, or
  2. You are the parent|legal guardian of the participant and am over 18 years of age
  3. Digitally signed and agreed to the Terms of Participation form above
  4. You verify you meet all the criteria for entrance according to COVID-19 regulations
  5. You also agree to the Exclusion Clause contained in the above PDF
The information obtained from this will not be released or revealed to any person without the written consent of the client. The information may be collated and used for statistical or education purposes with the right to privacy of the client always being retained.

First name:

Last name:

DOB:
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Open the calendar popup.

E-mail:

Phone:

Service Request:

Preferred Day/s & Time:

Emergency Contact:

Emergency No.:

What do you expect from training or treatments?:

List any medications your currently taking?:

Injuries/Medical conditions:

List any supplements your taking?:

List muscle or joint pain location:

Allergies:

Currently pregnant or trying?:

Feel any chest pain during physical activity?:

Do you have a heart condition?:

Do you know your Blood Pressure?:

Experienced a stroke?:

Has your family suffered heart disease before age 55? including grandparents?:

Do you have any head pains?:

Ever lose consciousness or loss of balance due to dizziness?:

Do you have asthma?:

Do you crrently smoke?:

Do you have chronic bronchitis:

Do you have diabetes:

Do you have epilepsy?:

What is your cholesterol level?:

UN-interrupted hours of sleep each night?:

Any recommendations for diet or exercise from your doctor:

Please descibe any special eating program you have:

Current training:

What type of exercise?:

How long have you done this?: